American Society Of Therapeutic Radiology And Oncology Research Articles

Intensification of radiation therapy for
 localized breast cancer in the settings of the
 COVID-19 pandemic: A literature review

Relevance: Since 2004, breast cancer steadily ranks first in the
 structure of the incidence of malignant neoplasms in the Republic of
 Kazakhstan in both sexes. In 2020, its share was 14.5% (vs. 15.2% in
 2019). Breast cancer also constantly ranks first in the structure of female cancer incidence, with 44.3‰ in 2020 (vs. 51.6‰in 2019).
 In the early 1980s, radiation therapy was a standard specialized
 treatment for breast cancer. The current realities of the COVID-19
 pandemic require a reorganization of healthcare facilities to determine the priorities. It is also important to balance the economic and
 clinical efficacy of radiotherapy methods applied.
 The study aimed to analyze the results of large randomized trials and compare breast cancer outcomes after hypofractionated and standard fractionation radiation treatment.
 Methods: We reviewed the results of large randomized trials
 of hypofractionated radiation therapy, emphasizing adequate
 patient selection according to the American Society of Therapeutic Radiology and Oncology (ASTRO) guidelines. Radiobiological
 aspects of hypofractionation were considered due to its implementation in clinical practice. The research materials were obtained from the “PubMed” database of evidence-based medicine
 by the keywords “radiotherapy,” “breast cancer,” “hypofractionation dose” for the period 2000-2021. Large randomized trials
 involving patients of any age diagnosed with stages T1-3, N0-1
 breast cancer, who underwent beam therapy in standard or hypofractionated mode, met the criteria for inclusion in this study.
 Results: According to the results of large randomized trials,
 the hypofractionated regimen is similar to the standard regimen in terms of late effects on normal tissues and ensures good
 control over the oncological process.
 Conclusions: Hypofractionation has proven effectiveness
 and safety and has lower late and/or acute radiation toxicity
 when treating early breast cancer. Hypofractionation can become a new standard of radiation therapy at early stages after
 breast-conserving surgery.

Intensification of radiation therapy for localized breast cancer in the settings of the COVID-19 pandemic: A literature review

Relevance: Since 2004, breast cancer steadily ranks first in the structure of the incidence of malignant neoplasms in the Republic of Kazakhstan in both sexes. In 2020, its share was 14.5% (vs. 15.2% in 2019). Breast cancer also constantly ranks first in the structure of female cancer incidence, with 44.3 0⁄0000 in 2020 (vs. 51.6 0⁄0000 in 2019). In the early 1980s, radiation
 therapy was a standard specialized treatment for breast cancer. The current realities of the COVID-19 pandemic require a reorganization of healthcare facilities to determine the priorities. It is also important to balance the economic and clinical efficacy of radiotherapy methods applied.
 The study aimed to analyze the results of large randomized trials and compare breast cancer outcomes after hypofractionated and standard fractionation radiation treatment.
 Methods: We reviewed the results of large randomized trials of hypofractionated radiation therapy, emphasizing good patient selection according to the American Society of Therapeutic Radiology and Oncology (ASTRO) guidelines. Radiobiological aspects of hypofractionation were considered due to its implementation in clinical practice. The research materials were obtained from the “PubMed” database of evidence-based medicine by the keywords “radiotherapy,” “breast cancer,” “hypofractionation dose” for the period of 2000-2021. Large randomized trials involving patients of any age diagnosed with stages T1-3, N0-1 breast cancer, who underwent beam therapy in standard or hypofractionated mode, met the criteria for inclusion in this study.
 Results: According to the results of large randomized trials, the hypofractionated regimen is similar to the standard regimen in terms of late effects on normal tissues and ensures reasonable control over the oncological process.
 Conclusions: Hypofractionation has proven effectiveness and safety and lower late and acute radiation toxicity when treating early breast cancer. Hypofractionation can become a new standard of radiation therapy at early stages after breast-conserving surgery.

Management of ductal carcinoma in situ with accelerated partial breast irradiation brachytherapy: Implications for guideline expansion

PurposeAccelerated partial breast irradiation (APBI) for patients with ductal carcinoma in situ (DCIS) is controversial, and the suitability criteria from the American Brachytherapy Society (ABS), American Society of Therapeutic Radiology and Oncology (ASTRO), and the European Society for Radiotherapy and Oncology (GEC-ESTRO) have important differences. Methods and MaterialsThis is a single-institution retrospective review of 169 consecutive patients with DCIS who underwent lumpectomy followed by APBI intracavitary brachytherapy from 2003 to 2018. Outcomes, including overall survival, recurrence-free survival (RFS), ipsilateral breast tumor recurrence, and distant metastasis, were estimated with the Kaplan–Meier method. ResultsThe median followup time was 62.5 months. Median age was 66 years (47–89 years). The majority of patients had estrogen receptor–positive disease (89%). Fifty patients (30%) had Grade 3 disease. Of the 142 patients with adequate pathology interpretation, 91 and 108 cases had margins ≥ 3 mm and ≥2 mm, respectively. Most patients (72%) were prescribed and started endocrine therapy. Of the patients evaluable for ABS criteria (N = 130), 97 met the suitability criteria. Of the patients evaluable for ASTRO criteria (N = 129), 42 were deemed cautionary and 33 were deemed unsuitable. Of the patients evaluable for GEC-ESTRO criteria (N = 143), 141 cases were at intermediate risk and two were at high risk. Five-year ipsilateral breast tumor recurrence, RFS, and overall survival were 0.6%, 97.7%, and 97.2%, respectively. The ABS, ASTRO, and GEC-ESTRO criteria failed to significantly predict for RFS. ConclusionsThese results, although limited by short-term followup, indicate that expansion of the eligibility criteria of APBI for patients with DCIS should be considered.

Prostate cancer trajectory-map: clinical decision support system for prognosis management of radical prostatectomy.

PurposeProstate cancer has a low mortality rate and requires persistent treatment; however, treatment decisions are challenging. Because prostate cancer is complex, the outcomes warrant thorough follow-up evaluation for appropriate treatment. Electronic health records (EHRs) do not present intuitive information. This study aimed to develop a Clinical Decision Support System (CDSS) for prognosis management of radical prostatectomy.MethodsWe used data from 5,199 prostate cancer patients from three hospitals’ EHRs in South Korea, comprising laboratory results, surgery, medication, and radiation therapy. We used open source R for data preprocessing and development of web-based visualization system. We also used R for automatic calculation functionalities of two factors to visualize the data, e.g., Prostate-Specific Antigen Doubling Time (PSADT), and four Biochemical Recurrence (BCR) definitions: American Society of Therapeutic Radiology and Oncology (ASTRO), Phoenix, consecutive PSA > 0.2 ng/mL, and PSA > 0.2 ng/mL.ResultsWe developed the Prostate Cancer Trajectory Map (PCT-Map) as a CDSS for intuitive visualization of serial data of PSA, testosterone, surgery, medication, radiation therapy, BCR, and PSADT.ConclusionsThe PCT-Map comprises functionalities for BCR and PSADT and calculates and visualizes the newly added patient data automatically in a PCT-Map data format, thus optimizing the visualization of patient data and allowing clinicians to promptly access patient data to decide the appropriate treatment.

Radical dose escalation by high-dose-rate brachytherapy for localized prostate cancer—Significance of prostate-specific antigen nadir level within 18 months as correlation for long-term biochemical control

PurposeHigh-dose-rate brachytherapy (HDR-BT) for dose escalation in localized prostate cancer has been established as one standard treatment option. However, long-term results at followup (FU) ≥5 years are usually needed to ensure robustness of reported outcomes. Potential benefit of salvage therapy is, nevertheless, higher when relapse is diagnosed early. This study aimed to solve this dilemma by evaluating the prostate-specific antigen (PSA) nadir for early prediction of long-term biochemical control. Methods and MaterialsCombined pelvis-external beam radiation/HDR-BT boost to EQD2 >100 Gy (α/β = 3) was performed in 459 consecutively treated patients. These patients with an FU ≥ 24 months were analyzed and stratified in PSA nadir (nPSA)-groups by PSA nadir within 18 months after radiotherapy (nPSA18). Kaplan–Meier/log-rank tests and Cox-regression models were used to compare the study endpoints. ResultsThe mean FU was 77 months. A PSA nadir within 18 months (nPSA18) <0.5 ng/mL was achieved in 222 patients with median time to reach nPSA18 of 7 months. The 5-year American Society of Therapeutic Radiology and Oncology (ASTRO) biochemical control (prostate-specific antigen disease-free survival) for the nPSA18 group <0.5 ng/mL was 89% and for the group ≥ 0.5 ng/mL, it was 78.6% (p = 0.011). nPSA18 was an independent predictor of cancer-specific survival, distant metastasis-free survival, and biochemical control (ASTRO) (p = 0.026, p = 0.020, and p = 0.01, respectively). ConclusionsThe present results suggest that the PSA nadir level within 18 months after radiotherapy may serve as an early parameter for long-term biochemical control according to ASTRO definitions following radical dose escalation by HDR-BT for prostate cancer. Excellent outcomes were associated with nPSA18 < 0.5 ng/mL.

Hypofractionated whole breast irradiation: new standard in early breast cancer after breast-conserving surgery.

Hypofractionated whole breast irradiation (HF-WBI) has been proved effective and safe and even better for late or acute radiation toxicity for early breast cancer. Moreover, it improves patient convenience, quality of life and is expected to be advantageous in the medical care system by reducing overall cost. In this review, we examined key randomized trials of HF-WBI, focusing on adequate patient selection as suggested by the American Society of Therapeutic Radiology and Oncology (ASTRO) guideline and the radiobiologic aspects of HF-WBI in relation to its adoption into clinical settings. Further investigation to identify the current practice pattern or cost effectiveness is warranted under the national health insurance service system in Korea.

Choosing Wisely: Opportunities for improving value of cancer care in the Deep South.

13 Background: Under the Choosing Wisely (CW) Campaign, the American Society of Clinical Oncology (ASCO) and the American Society of Therapeutic Radiology and Oncology (ASTRO) recommend against non-evidence-based costly medications, tests, and procedures. CW recommendation adherence in the Deep South is largely unknown, and opportunities to reduce overuse and costs may exist. Methods: Analysis of administrative claims and tumor registry data from 12 cancer centers of the University of Alabama Health System Cancer Community Network, for Medicare beneficiaries ≥65 years old with cancer. Main outcome: percent of beneficiaries adhering to 9 CW recommendations. Results: 2012-2015 (Q1) adherence varied across CW recommendations and cancer centers, and increased over time for CW 2 and 7, decreased for 3, 5, and 6, and did not change for others. Conclusions: Opportunities to improve quality and value of cancer care exist in the Deep South. Research should understand how to minimize use of non-evidence based medications, tests, and procedures. [Table: see text]

Low-dose rate brachytherapy of the prostate in elderly patients

This study evaluated the biochemical diseasefree survival (bDFS) rate, overall survival rate (OS) and toxicity after low-dose rate I(125) permanent-implant prostate brachytherapy (LDR-BRT) in elderly patients affected by prostate cancer. Patients aged ≥65 years with a diagnosis of prostate cancer and treated at our institution were retrospectively evaluated. All patients received LDR-BRT as monotherapy; the prescribed dose was 145 Gy to the prostate. Patients were stratified according to the National Comprehensive Cancer Network (NCCN) recurrence risk groups. Biochemical failure was defined according to the American Society of Therapeutic Radiology and Oncology (ASTRO) criteria. The Radiation Therapy Oncology Group (RTOG) scale was used for toxicity. The bDFS was calculated from implant date to biochemical recurrence. Between June 2003 and December 2008, 80 elderly patients with a median age of 75 (range, 65-86) years were treated with LDR-BRT: 51 low risk (64%), and 29 intermediate risk (36%). Over a median follow-up period of 53 (range, 28-94) months, the global actuarial 5-year bDFS rate was 91.3% and the 5-year OS was 95%. Toxicity was mild: late grade-3 genitourinary toxicity was observed in only four patients (5%). Our data suggest that LDR-BRT is effective and safe as monotherapy in elderly patients.

A retrospective analysis after low-dose-rate prostate brachytherapy with permanent 125I seed implant: clinical and dosimetric results in 70 patients

To evaluate the biochemical disease-free survival (bDFS) rate after (125)I permanent-implant prostate brachytherapy. Patients with a diagnosis of prostate adenocarcinoma and adequate PSA follow-up were selected for this retrospective study. Brachytherapy with permanent (125)I seeds was performed as monotherapy, with a prescribed dose of 145 Gy to the prostate. Patients were stratified into recurrence risk groups according to the National Comprehensive Cancer Network (NCCN) guidelines. Biochemical failure was defined using the American Society of Therapeutic Radiology and Oncology (ASTRO) guidelines. The post-implant D90 (defined as the minimum dose covering 90% of the prostate) was obtained for each patient. Two cutoff points were used to test the correlation between D90 and bDFS results: 130 Gy and 140 Gy. bDFS was calculated from the implant date to the date of biochemical recurrence. Univariate and multivariate analysis were performed using the SPSS software and included clinical stage, pretreatment PSA, Gleason score (GS), androgen deprivation therapy, D90, and risk groups. In the univariate analysis we used a cutoff point of 5.89 ng/mL for PSA and 5 for GS. From June 2003 to April 2007, 70 patients were analyzed. The patients' distribution into recurrence risk groups was as follows: 39 patients (56%) in the low-risk group, 23 patients (33%) in the intermediate-risk group, and 8 patients (11%) in the high-risk group. At a median follow-up of 47 months (range, 19-70 months) bDFS was 88.4%, with a global actuarial 5-year bDFS of 86%. Disease-related factors including initial PSA level, GS and risk group were significant predictors of biochemical failure ( P = 0.01, P = 0.01, P = 0.006, respectively). In multivariate analysis, risk group (P = 0.005) and GS (P = 0.03) were statistically significant. Our data are in agreement with those in the literature and, despite the short follow-up, confirm the advantage of brachytherapy for patients at low and intermediate risk of recurrence.

A retrospective analysis after low-dose-rate prostate brachytherapy with permanent (125)I seed implant: clinical and dosimetric results in 70 patients.

To evaluate the biochemical disease-free survival (bDFS) rate after (125)I permanent-implant prostate brachytherapy. Patients with a diagnosis of prostate adenocarcinoma and adequate PSA follow-up were selected for this retrospective study. Brachytherapy with permanent (125)I seeds was performed as monotherapy, with a prescribed dose of 145 Gy to the prostate. Patients were stratified into recurrence risk groups according to the National Comprehensive Cancer Network (NCCN) guidelines. Biochemical failure was defined using the American Society of Therapeutic Radiology and Oncology (ASTRO) guidelines. The post-implant D90 (defined as the minimum dose covering 90% of the prostate) was obtained for each patient. Two cutoff points were used to test the correlation between D90 and bDFS results: 130 Gy and 140 Gy. bDFS was calculated from the implant date to the date of biochemical recurrence. Univariate and multivariate analysis were performed using the SPSS software and included clinical stage, pretreatment PSA, Gleason score (GS), androgen deprivation therapy, D90, and risk groups. In the univariate analysis we used a cutoff point of 5.89 ng/mL for PSA and 5 for GS. From June 2003 to April 2007, 70 patients were analyzed. The patients' distribution into recurrence risk groups was as follows: 39 patients (56%) in the low-risk group, 23 patients (33%) in the intermediate-risk group, and 8 patients (11%) in the high-risk group. At a median follow-up of 47 months (range, 19-70 months) bDFS was 88.4%, with a global actuarial 5-year bDFS of 86%. Disease-related factors including initial PSA level, GS and risk group were significant predictors of biochemical failure ( P = 0.01, P = 0.01, P = 0.006, respectively). In multivariate analysis, risk group (P = 0.005) and GS (P = 0.03) were statistically significant. Our data are in agreement with those in the literature and, despite the short follow-up, confirm the advantage of brachytherapy for patients at low and intermediate risk of recurrence.

Abstract ES5-1: Emerging Radiation Techniques — The Fast and the Furious

Abstract The equivalence of breast conserving therapy (BCT) to mastectomy in the treatment of women with early-stage breast cancer has been demonstrated in several phase III trials with over 25 years of follow-up. Despite the undisputed efficacy of this treatment approach, recent investigations have explored methods to either reduce the overall time, inconvenience or toxicity of its application. These approaches have included (1) accelerating the dose delivery scheme, (2) reducing the treatment target to less than whole breast, or (3) identifying subgroups of women in which adjuvant radiation therapy (RT) following lumpectomy can be safely omitted Accelerated partial breast irradiation (APBI) has been investigated as a possible option that incorporates both a decrease in the overall treatment time and a reduction in the amount of normal tissue irradiated. Several different treatment techniques have been developed for the delivery of APBI. Within the United States, three ‘classic’ techniques dominate and include multicatheter interstitial brachytherapy, balloon catheter brachytherapy and three-dimensional conformal external beam radiotherapy (3D-CRT). In Europe, in addition to multicatheter brachytherapy, intraoperative radiotherapy has been central to their APBI experience. The majority of results with APBI to date have provided comparable 5 and 10-year outcomes to whole breast irradiation (WBI) in highly selected, low risk patients. In recognition of the success of these single institution experiences, nine phase III studies have now been initiated or completed in the United States and Europe. Despite limited long-term clinical data, the use of APBI outside of clinical trials has increased sharply. Given these concerns, the American Society of Therapeutic Radiology and Oncology (ASTRO) Health Services Research Committee convened a Task Force of breast cancer experts to develop a consensus statement addressing patient selection criteria and best practices for the application of APBI outside of clinical trials. These recently published recommendations were based on the results of a systematic literature review of the limited APBI data and were also supplemented by the expert opinions of the Task Force members using data applying WBI to treat patients. Accelerated whole breast irradiation (AWBI) has also been explored as a potential treatment option to deliver adjuvant irradiation after lumpectomy. Similar to APBI, the goals of this treatment approach are to theoretically increase the frequency that BCT is chosen as a treatment option, provide a logistically faster, convenient and more accessible method for BCT and potentially improve overall quality-of-life for early stage breast cancer patients. The data on AWBI include several phase III trials performed in Europe and North America with some trials reporting results at 10 years. In recognition of the concerns related to appropriate selection criteria for the application of this treatment approach, the ASTRO Health Services Research Committee also convened a Task Force of breast cancer experts to develop a consensus statement addressing patient selection criteria and best practices for the application of AWBI. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr ES5-1.

Limitations of the American Society of Therapeutic Radiology and Oncology (ASTRO) Consensus Panel Guidelines on the Use of Accelerated Partial Breast Irradiation

We applied the American Society of Therapeutic Radiology and Oncology (ASTRO) Consensus Panel (CP) guidelines for the use of accelerated partial breast irradiation (APBI) to patients treated with this technique to determine their ability to differentiate patients with significantly different clinical outcomes. One hundred ninety-nine patients treated with APBI and 199 with whole breast irradiation (WBI) (matched for tumor size, nodal status, age, margins, receptor status, and tamoxifen use) were stratified into the three ASTRO CP levels of suitability (suitable [S], cautionary [C], and unsuitable [U]) to assess rates of ipsilateral breast tumor recurrence (IBTR), regional nodal failure (RNF), distant metastases (DM), disease-free survival (DFS), cause-specific survival (CSS), and overall survival (OS) based upon CP category. Median follow-up was 11.1 years. Analysis of the APBI and WBI patient groups, either separate or together (n = 398), did not demonstrate statistically significant differences in 10-year actuarial rates of IBTR when stratified by the three ASTRO groups. Regional nodal failure and DM were generally progressively worse when comparing the S to C to U CP groups. However, when analyzing multiple clinical, pathologic or treatment related variables, only patient age was associated with IBTR using WBI (p = 0.002). The ASTRO CP suitable group predicted for a low risk of IBTR; however, the C and U groups had an equally low risk of IBTR supporting the need for continued refinement of patient selection criteria as additional outcome data become available and for the continued accrual of patients to phase III trials.

Five-year Outcome of Patients Classified in the “Unsuitable” Category Using the American Society of Therapeutic Radiology and Oncology (ASTRO) Consensus Panel Guidelines for the Application of Accelerated Partial Breast Irradiation: An Analysis of Patients Treated on the American Society of Breast Surgeons MammoSite® Registry Trial

We applied the ASTRO Consensus Panel (CP) guidelines for the application of accelerated partial breast irradiation (APBI) to patients treated with this technique on the ASBS MammoSite® registry trial to determine potential differences in outcome of patients classified in the "unsuitable" category. Of 1,449 cases treated with APBI on the registry trial, 176 fit the criteria for the unsuitable category: 130 cases were <50 years of age, 13 had positive margins, 38 had positive nodes, 6 had tumors >3 cm, and 9 had an EIC >3 cm. Rates of ipsilateral breast tumor recurrence (IBTR) and regional nodal failure (RNF) were assessed. Median follow-up was 53.6 months. The 5-year actuarial rate of IBTR for unsuitable cases was 5.25% (RNF rate was 0.63%). By comparison, the 5-year actuarial IBTR rates for various subsets of patients were: all 1,449 cases, 3.89% (p = 0.2365); all 1,449 cases excluding unsuitable cases [n =1,273] (3.6%, p =0.1683); invasive only cases [n = 1,255] (3.86%, p = 0.2464); and invasive only cases excluding unsuitable invasive cases [n =1,105] (3.89%, p = 0.2396). On univariate analysis for variables potentially associated with IBTR in all 1,255 cases with invasive cancer (including age, tumor size, nodal status, overall stage, margin status, ER status, presence of an EIC, and ASTRO unsuitable category), only negative ER (-) status was associated with the 5-year rate of IBTR (p = 0002). No other variable (including unsuitable CP designation) was associated with IBTR. The ASTRO CP guideline designation of unsuitable did not differentiate a subset of patients with a significantly worse rate of IBTR when treated with the MammoSite® breast brachytherapy catheter to deliver APBI.

Limitations of the American Society of Therapeutic Radiology and Oncology Consensus Panel Guidelines on the Use of Accelerated Partial Breast Irradiation

We applied the American Society of Therapeutic Radiology and Oncology (ASTRO) Consensus Panel (CP) guidelines for the use of accelerated partial breast irradiation (APBI) to patients treated with this technique to determine the ability of the guidelines to differentiate patients with significantly different clinical outcomes. A total of 199 patients treated with APBI and 199 with whole-breast irradiation (WBI) (matched for tumor size, nodal status, age, margins, receptor status, and tamoxifen use) were stratified into the three ASTRO CP levels of suitability ("suitable," "cautionary," and "unsuitable") to assess rates of ipsilateral breast tumor recurrence (IBTR), regional nodal failure, distant metastases, disease-free survival, cause-specific survival, and overall survival based on CP category. Median follow-up was 11.1 years. Analysis of the APBI and WBI patient groups, either separately or together (n = 398), did not demonstrate statistically significant differences in 10-year actuarial rates of IBTR when stratified by the three ASTRO groups. Regional nodal failure and distant metastasis were generally progressively worse when comparing the suitable to cautionary to unsuitable CP groups. However, when analyzing multiple clinical, pathologic, or treatment-related variables, only patient age was associated with IBTR using WBI (p = 0.002). The ASTRO CP suitable group predicted for a low risk of IBTR; however, the cautionary and unsuitable groups had an equally low risk of IBTR, supporting the need for continued refinement of patient selection criteria as additional outcome data become available and for the continued accrual of patients to Phase III trials.

Excellent Ten-Year Results following Accelerated Partial Breast Irradiation with Multicatheter Interstitial Brachytherapy in Unsuitable Patients as Categorized by the American Society of Therapeutic Radiology and Oncology Consensus Panel

Purpose: We report ten-year local control and overall survival outcomes in patients with early stage breast cancer who fit criteria for the “unsuitable” category (e.g., high risk) as defined by the current American Society of Therapeutic Radiology and Oncology (ASTRO) Consensus Panel (CP) guidelines, following breast conserving therapy with accelerated partial breast irradiation (APBI) employing multicatheter interstitial brachytherapy (MIB).

International Patterns of Practice in Palliative Radiotherapy for Painful Bone Metastases: Evidence-Based Practice?

To determine patterns of practice in palliative radiation therapy (RT) for painful bone metastases (BM) in view of randomized controlled trials and meta-analyses demonstrating the equivalence of single fraction (SF) and multi-fraction schedules. Radiation Oncologist members of the American Society of Therapeutic Radiology and Oncology (ASTRO), the Canadian Association of Radiation Oncology (CARO), and fellows of the Royal Australian and New Zealand College of Radiology (FRANZCR) were invited to participate. Respondents were asked to rate factors that influenced decision-making. Five case scenarios were presented; respondents were asked whether they would recommend RT, and if so, what dose and fractionation schedule. Descriptive statistics were compiled as proportions and medians (ranges), and two-sided Fisher's exact test was performed. A total of 962 eligible responses from 47 countries were received from respondents in practice a median of 14 years (range 1-49 years). A total of 49.1% were trained and 50.6% currently practice in the United States. 25.6% (185/722) of ASTRO respondents work in private practice, versus 13.9% (FRANZCR; p = 0.003) and 0% (CARO; p < 0.0001). Prognosis, spinal cord compression (SCC) and performance status were the top three factors taken into account by ASTRO and FRANZCR members; for CARO members, factors were SCC, evidence and prognosis. Median dose cited by ASTRO members was 30 Gy/10 for all cases (except re-treatment), compared to 8 Gy/1-20 Gy/5 for other respondents. For a solitary BM, on average 9.9% of ASTRO members would prescribe SF, compared to 29.6% (FRANZCR; p < 0.0001) and 33.8% (CARO; p < 0.0001). In the setting of neuropathic pain, 5.0% (33/654), 9.0% (9/100) and 16.5% (19/115) would use SF, respectively (p = 0.05 ASTRO vs. FRANZCR; p < 0.0001 ASTRO vs. CARO). Significantly fewer ASTRO respondents (25.7%) would use SF to retreat painful BM compared to 45.3% (FRANZCR; p = 0.0004) and 59.9% (CARO; p < 0.0001). Patients with painful bone metastases continue to be treated with multiple fraction schedules, especially by ASTRO members, despite multiple trials reporting the equivalence of SF. This suggests factors other than published evidence more strongly influence patterns of RT prescription. Multivariate analysis is underway to explore factors contributing to this variation in clinical practice.

Asians with Localized Prostate Cancer Treated with 3-Dimensional Conformal Radiation Therapy and Adjuvant Hormonal Therapy: Comparing Phoenix and American Society of Therapeutic Radiology and Oncology (ASTRO) Definitions in an Asian Population

Conformal radiotherapy with adjuvant androgen suppression is used in our center to treat localized prostate cancer. We compare Phoenix as an alternative to American Society of Therapeutic Radiology and Oncology (ASTRO) for defining biochemical failure. Our primary aim was to assess the Phoenix and ASTRO definitions of biochemical failure in a population of mainly Asian men with early localized prostate cancer treated with conformal radiotherapy with and without androgen ablation. We retrospectively analyzed 141 patients who were treated for T1/T2 cancer of the prostate in our center from January 1997 to June 2002 with a mean duration of follow-up of 62 months. Outcomes were analyzed by using both Phoenix and ASTRO definitions of biochemical failure as well as clinical failure. The Phoenix definition of biochemical failure was superior as measured by sensitivity, specificity, positive and negative predictive values, accuracy, and a greater concordance with clinical outcome as measured by Kappa analysis. The ASTRO definition helped to standardize reporting of biochemical failures post-radiotherapy but inadequacies have been identified especially when adjuvant hormone therapy has been given. The Phoenix definition has been noted to be a more accurate and precise description of biochemical failure in international series, and we find this to be true in our Asian population as well.

Differences in Pattern of Practice in Radiation Therapy for Patients With Non-Small Cell Lung Cancer (NSCLC) Between Physicians in China and the United States (US)

Purpose/Objective(s)To study the pattern of practice in radiation therapy (RT) for NSCLC patients in China and compare the results with that of US.Materials/MethodsStudy questionnaires were designed by a panel of 8 Board certified radiation oncologists. The survey was sent through email to radiation oncologist members of American Society of Therapeutic Radiology and Oncology (ASTRO) in September, 2006, and to Chinese radiation oncologists in January, 2007. The results were collected online in March, 2007. There were a total of 492 responses: 425 from the US and 67 from China.ResultsChinese respondents saw an average of 14 new cases monthly, significantly more than US physicians (p < 0.001). The choices of treatment decision and RT prescription were heterogeneous among respondents. There was a significant difference in choices of radiation regimens for stage I peripherally located disease: 20% Chinese vs 34% of US chose conventional fractionated RT (p < 0.00), 43% Chinese vs 19% of US chose stereotactic RT (p < 0.001), 0% Chinese vs 14% of US chose stereotactic RT 18-20 Gy × 3, and 23% Chinese vs 1.5% of US chose 6 Gy ×10 (p < 0.001). For stage I centrally located disease, the majority of respondents selected conventional fractionated RT in both countries: 28% of Chinese vs 8% of US chose stereotactic RT (p < 0.001). For stage II disease, a majority of respondents chose concurrent chemoradiation (64% Chinese vs 85% of US, p < 0.001), with radiation dose of 60–70 Gy in 1.8–2 Gy daily fractions (79% of US vs 69% Chinese). For stage III patients with a performance score of 70–100%, the dominant pattern of practice was concurrent chemoradiation followed by adjuvant chemotherapy (61% Chinese vs 85% of US respondents, p < 0.001); 16% Chinese vs 1% of US chose sequential chemoradiation (p < 0.001). For patients with performance score of 50–60%, 36% of Chinese and 41% of US respondents chose fractionated RT alone, 0% Chinese vs 11% of US chose concurrent chemoradiation followed by adjuvant chemotherapy, 22% Chinese vs 17% of US chose chemotherapy followed by RT, 13% Chinese vs 20% of US chose RT followed by chemotherapy (p < 0.001). Regarding choices of dose fractionation, 45% Chinese vs 79% of US respondents (p < 0.001) chose 60–70 Gy in 1.8–2 Gy daily fractions, 48% Chinese vs 13% of US chose exactly 60 Gy in 2 Gy daily fractions (p < 0.001). For stage IV disease with good performance score, 50% Chinese 27% of US respondents chose 2 Gy × 30 (p = 0.001), fewer Chinese respondents chose lower doses or no radiation (p = 0.001). For patients with stage IV with hemoptysis or obstructive lung disease with asymptomatic distant metastasis, Chinese respondents tended to choose chemotherapy followed by RT (39%) more than 3 Gy ×10 followed by chemotherapy (10%), which is the opposite of respondents of the US (5% vs 43%, p < 0.001).ConclusionsThere is a significant difference in the pattern of practice for NSCLC patients between radiation oncologists from China and the US. Fewer Chinese physicians selected larger fraction size for stereotactic RT, higher total dose for fractionated RT, and concurrent chemoradiation for stage II/III NSCLC, and aggressive RT for stage IV diseases. Purpose/Objective(s)To study the pattern of practice in radiation therapy (RT) for NSCLC patients in China and compare the results with that of US. To study the pattern of practice in radiation therapy (RT) for NSCLC patients in China and compare the results with that of US. Materials/MethodsStudy questionnaires were designed by a panel of 8 Board certified radiation oncologists. The survey was sent through email to radiation oncologist members of American Society of Therapeutic Radiology and Oncology (ASTRO) in September, 2006, and to Chinese radiation oncologists in January, 2007. The results were collected online in March, 2007. There were a total of 492 responses: 425 from the US and 67 from China. Study questionnaires were designed by a panel of 8 Board certified radiation oncologists. The survey was sent through email to radiation oncologist members of American Society of Therapeutic Radiology and Oncology (ASTRO) in September, 2006, and to Chinese radiation oncologists in January, 2007. The results were collected online in March, 2007. There were a total of 492 responses: 425 from the US and 67 from China. ResultsChinese respondents saw an average of 14 new cases monthly, significantly more than US physicians (p < 0.001). The choices of treatment decision and RT prescription were heterogeneous among respondents. There was a significant difference in choices of radiation regimens for stage I peripherally located disease: 20% Chinese vs 34% of US chose conventional fractionated RT (p < 0.00), 43% Chinese vs 19% of US chose stereotactic RT (p < 0.001), 0% Chinese vs 14% of US chose stereotactic RT 18-20 Gy × 3, and 23% Chinese vs 1.5% of US chose 6 Gy ×10 (p < 0.001). For stage I centrally located disease, the majority of respondents selected conventional fractionated RT in both countries: 28% of Chinese vs 8% of US chose stereotactic RT (p < 0.001). For stage II disease, a majority of respondents chose concurrent chemoradiation (64% Chinese vs 85% of US, p < 0.001), with radiation dose of 60–70 Gy in 1.8–2 Gy daily fractions (79% of US vs 69% Chinese). For stage III patients with a performance score of 70–100%, the dominant pattern of practice was concurrent chemoradiation followed by adjuvant chemotherapy (61% Chinese vs 85% of US respondents, p < 0.001); 16% Chinese vs 1% of US chose sequential chemoradiation (p < 0.001). For patients with performance score of 50–60%, 36% of Chinese and 41% of US respondents chose fractionated RT alone, 0% Chinese vs 11% of US chose concurrent chemoradiation followed by adjuvant chemotherapy, 22% Chinese vs 17% of US chose chemotherapy followed by RT, 13% Chinese vs 20% of US chose RT followed by chemotherapy (p < 0.001). Regarding choices of dose fractionation, 45% Chinese vs 79% of US respondents (p < 0.001) chose 60–70 Gy in 1.8–2 Gy daily fractions, 48% Chinese vs 13% of US chose exactly 60 Gy in 2 Gy daily fractions (p < 0.001). For stage IV disease with good performance score, 50% Chinese 27% of US respondents chose 2 Gy × 30 (p = 0.001), fewer Chinese respondents chose lower doses or no radiation (p = 0.001). For patients with stage IV with hemoptysis or obstructive lung disease with asymptomatic distant metastasis, Chinese respondents tended to choose chemotherapy followed by RT (39%) more than 3 Gy ×10 followed by chemotherapy (10%), which is the opposite of respondents of the US (5% vs 43%, p < 0.001). Chinese respondents saw an average of 14 new cases monthly, significantly more than US physicians (p < 0.001). The choices of treatment decision and RT prescription were heterogeneous among respondents. There was a significant difference in choices of radiation regimens for stage I peripherally located disease: 20% Chinese vs 34% of US chose conventional fractionated RT (p < 0.00), 43% Chinese vs 19% of US chose stereotactic RT (p < 0.001), 0% Chinese vs 14% of US chose stereotactic RT 18-20 Gy × 3, and 23% Chinese vs 1.5% of US chose 6 Gy ×10 (p < 0.001). For stage I centrally located disease, the majority of respondents selected conventional fractionated RT in both countries: 28% of Chinese vs 8% of US chose stereotactic RT (p < 0.001). For stage II disease, a majority of respondents chose concurrent chemoradiation (64% Chinese vs 85% of US, p < 0.001), with radiation dose of 60–70 Gy in 1.8–2 Gy daily fractions (79% of US vs 69% Chinese). For stage III patients with a performance score of 70–100%, the dominant pattern of practice was concurrent chemoradiation followed by adjuvant chemotherapy (61% Chinese vs 85% of US respondents, p < 0.001); 16% Chinese vs 1% of US chose sequential chemoradiation (p < 0.001). For patients with performance score of 50–60%, 36% of Chinese and 41% of US respondents chose fractionated RT alone, 0% Chinese vs 11% of US chose concurrent chemoradiation followed by adjuvant chemotherapy, 22% Chinese vs 17% of US chose chemotherapy followed by RT, 13% Chinese vs 20% of US chose RT followed by chemotherapy (p < 0.001). Regarding choices of dose fractionation, 45% Chinese vs 79% of US respondents (p < 0.001) chose 60–70 Gy in 1.8–2 Gy daily fractions, 48% Chinese vs 13% of US chose exactly 60 Gy in 2 Gy daily fractions (p < 0.001). For stage IV disease with good performance score, 50% Chinese 27% of US respondents chose 2 Gy × 30 (p = 0.001), fewer Chinese respondents chose lower doses or no radiation (p = 0.001). For patients with stage IV with hemoptysis or obstructive lung disease with asymptomatic distant metastasis, Chinese respondents tended to choose chemotherapy followed by RT (39%) more than 3 Gy ×10 followed by chemotherapy (10%), which is the opposite of respondents of the US (5% vs 43%, p < 0.001). ConclusionsThere is a significant difference in the pattern of practice for NSCLC patients between radiation oncologists from China and the US. Fewer Chinese physicians selected larger fraction size for stereotactic RT, higher total dose for fractionated RT, and concurrent chemoradiation for stage II/III NSCLC, and aggressive RT for stage IV diseases. There is a significant difference in the pattern of practice for NSCLC patients between radiation oncologists from China and the US. Fewer Chinese physicians selected larger fraction size for stereotactic RT, higher total dose for fractionated RT, and concurrent chemoradiation for stage II/III NSCLC, and aggressive RT for stage IV diseases.

Changes on endorectal MRI during neoadjuvant hormonal therapy for prostate cancer and biochemical outcome in men managed using radiation therapy: A prospective phase II Cancer and Leukemia Group B study

5072 Background: We prospectively determined whether changes in tumor volume (TV) on 1.5 Tesla endorectal magnetic resonance imaging (eMRI) during neoadjuvant androgen suppression therapy (AST) were associated with biochemical outcome after radiation and 6 months of AST. Methods: Between May, 1996 and April, 2001,180 men with T1c-T3c non-metastatic adenocarcinoma of the prostate cancer were registered. Fifteen were found to be ineligible leaving 165 men who had a eMRI TV measurement at baseline and following 2 months of neoadjuvant AST. An eMRI response was defined as &gt; 10% reduction in the volume of all lesions consistent with prostate cancer. In 32 men, the institutional MR radiologist could not completely assess the TV leaving 133 for analysis. A proportional hazards model was used to assess whether a significant association existed between eMRI response and time to prostate-specific antigen (PSA) failure following registration adjusting for PSA level (continuous), Gleason score (8 to 10 or 7 versus 6 or less) and stage (T3 versus T1, 2). PSA failure was defined as 2 consecutive rises of 0.2 above 1.0 ng/ml (PSA fail) and according to the 1997 and the 2006 American Society of Therapeutic Radiology and Oncology (ASTRO) consensus definitions. Results: The median age and PSA level of the study cohort were 70 years and 10.7 ng/ml respectively. An eMRI response was noted in 112 (84%) men and 85, 47, and 47 men experienced PSA failure based on the 1997, 2006 ASTRO consensus and PSA fail definitions respectively. After a median follow up of 6.7 years and adjusting for known prognostic factors, there was a statistically significant association between eMRI defined tumor response and time to PSA failure using the 1997 (p = 0.04) and 2006 (p = 0.009) ASTRO consensus definitions and a near significant association (p = 0.08) using PSA fail. Conclusion: Men lacking a &gt; 10% reduction in the eMRI defined TV during neoadjuvant AST are at increased risk for recurrence following radiation and AST. Therefore, eMRI enables the early documentation of androgen insensitive disease and identifies men for trials evaluating outcome when non-AST based approaches are combined with radiation and AST. No significant financial relationships to disclose.

Patterns of practice in radiation therapy for non-small cell lung cancer among members of American Society of Therapeutic Radiology and Oncology

7693 Purpose: To investigate the dominant pattern of current practice in radiation therapy (RT) for lung cancer among members of American Society of Therapeutic Radiology and Oncology (ASTRO). Methods: A 35-item survey was designed by a panel of 8 board certified radiation oncologists regarding RT for lung cancer. Surveys were sent through email to 3,800 radiation oncologist members on September 10, 2006, with the results collected online on December 10, 2006. Here we report results on radiation decisions for non-small cell lung cancer (NSCLC). Results: The response rate was 19% (n = 727). The respondents saw an average of 8 consults (ranged 1–25) monthly during the survey time (summing up to a total of &gt;60,000 new cases yearly). For stage I peripherally located NSCLC, 33%, 10% and 20% of respondents reported conventional fractionated, hypofractioned and stereotactic RT, respectively. Another 25% of respondents would have offered stereotactic RT if this technique were available at their center. For stage I centrally located tumors, 78% of respondents did not agree with, but 10% selected, stereotactic RT. For stage II and III, 76% of respondents selected 60–70 Gy in 1.8–2 Gy with chemotherapy. With regard to the combined modality approach for stage II and III disease, 76–77% of respondents selected concurrent chemoRT followed by adjuvant chemotherapy, and 11–16% sequential followed by concurrent chemoRT for patients with good performance status. For stage IV NSCLC with remarkable local disease, the consideration of RT ranged from 0 Gy, 3 Gyx10, 3 Gyx15, 2.5 Gyx20, to 2 Gyx30 in 27%, 17%, 8%, 13%, and 21% of respondents, respectively. Conclusions: The dominant pattern of practice for stage II/III disease is concurrent chemoRT, consistent with results of phase III trials. The treatment decisions for stage I and IV disease are diverse, partially due to technology advancement and the lack of large phase III trials. No significant financial relationships to disclose.